Communication Supports

Enabling Communication in Minimally Verbal Pre-school Children with Autism Spectrum Disorder

This mini-site was made by a group of University of Edinburgh medical students who studied this subject over 10 weeks as part of the SSC. Their work was impressive and could be a useful resource for the community. Therefore it was decided to embed their report within the DART site for public access. Please bear in mind when browsing these pages that this is the result of an undergraduate project and, while it is based in the published evidence, it does not reflect the opinions of a trained professional such as a speech and language therapist.

Objective: To create a tool for parents/carers of minimally verbal pre-school children with autism spectrum disorder (ASD) which will give a summary of the communication aids available to their child. This tool will encompass:


Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition that affects how a person communicates with and relates to other people and how they make sense of the world around them. It is a heterogeneous condition which affects different people in different ways, with sufferers experiencing a range of difficulties with social communication and social interaction, as well as restrictive and repetitive patterns of behaviour. This may or may not be accompanied by intellectual disability.1,2 Global prevalence of ASD is estimated to be 62 per 10 000, with 38.9 per 10 000 children being affected in the UK.3,4 The incidence of ASD is higher among boys than girls.2


Figure 1 – An 18 month old boy with ASD obsessively stacking cans.

The DSM-IV/ICD-10 diagnostic criteria for ASD encompass social, communicative and behavioural features. These include deficits in social-emotional reciprocity, for example, being unable to carry out a conversation, a decreased emotional response or a complete lack of response to social interactions. They also include deficits in non-verbal communicative behaviours, such as abnormalities in eye contact and body language or a lack of understanding and use of gestures and facial expressions. Difficulties may also be experienced in developing, maintaining and understanding relationships. In addition, sufferers of ASD may experience restricted, repetitive patterns of behaviour (as shown in figure 1). These include repetitive motor movements, repetitive speech or repeatedly using certain objects, inflexible routines, highly restricted interests requiring an intense focus and hypersensitivity towards certain sounds. Symptoms usually lead to a diagnosis by the age of 3.5

little girl

Figure 2 – A little girl making a gesture.

Communication difficulties tend to be the earliest observed symptom among children with ASD, with verbal communication being completely absent among 25-61% of children.6 Pre-school children in particular tend to experience reduced frequency and diversity of communicative forms such as babbling, gestures, consonants in syllables, words and word combinations. Gestures are often isolated and less integrated with speech (as seen in figure 2). Initiation of social communicative acts is reduced, making it difficult for children to indicate their needs and desires. There is decreased initiation of and response to attempts by the parent/ carer to share attention in experiences and objects, such as toys. Young children also experience difficulty in play and the development of symbols into language. Early expressive and receptive language delays are seen. However, children with ASD tend to be skilled with single word vocabulary.7 Other signs of impaired communication include speaking in an abnormal tone of voice, or with an odd rhythm or pitch, repeating the same words or phrases, responding to a question by repeating it rather than answering it (echolalia), referring to themselves in the third person, using language incorrectly, not comprehending simple directions, statements or questions and taking what is said too literally i.e. not understanding sarcasm.8

There is great variability in outcomes among individuals with ASD. If communication deficits are left untreated, they can have a vast impact on the lives of children with ASD and their families, and are likely to persist into adulthood. Children struggle to understand what is happening around them and may be unable to predict what will happen next. This creates anxiety and insecurity, which children frequently express through obsessive behaviours such a rocking or even throwing tantrums. Children often experience failure in social situations, which negatively impacts their confidence and self-esteem. This can result in challenging behaviour at home and at school. They may also be more vulnerable to abuse and bullying.9 Parents of children with ASD often face great difficulties which can lead to an increase in parenting stress and experiences of physical and mental health problems.10

Early interventions for improving communication skills can decrease behavioural problems, provide more opportunities for school and community involvement and increase levels of joint attention, as well as improving verbalisation, mean length of utterance and spontaneity of language use.6 A number of communication aids now exist which aim to assist pre-school children with ASD. These include:

Makaton Signing



Facilitated Communication

This website will aim to explore these communication aids, establishing their advantages and disadvantages to provide information for parents and carers of minimally verbal pre-school children and help them to assess the different communication aids available to them.

A note from the authors: The mini-site has not been peer reviewed. We certify that this website is our own work and that we have authorisation to use all the content (e.g. figures/images) used in this website.We would like to thank Dr Sue Fletcher-Watson for her guidance throughout this project.